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1 The Transition to ICD-10 and Version 5010 David W. Saÿen Regional Administrator San Francisco Regional Office Centers for Medicare & Medicaid Services April 6, 2011 Topics To Be Covered What is Changing? Why the Change? Why the Change? ICD-10: Key Dates and Deadlines CMS’ Dual Role Implementation CMS ICD-10 Program Management Program management Key outreach activities/findings and monitoring GEM Updates and Partial Code Freeze Resources to Help you Prepare Summary and Closing Remarks

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  • 1

    The Transition to ICD-10 and Version 5010

    David W. SaÿenRegional AdministratorSan Francisco Regional OfficeCenters for Medicare & Medicaid Services

    April 6, 2011

    Topics To Be Covered

    • What is Changing?• Why the Change?Why the Change?• ICD-10: Key Dates and Deadlines• CMS’ Dual Role Implementation • CMS ICD-10 Program Management

    – Program management– Key outreach activities/findings and monitoring

    • GEM Updates and Partial Code Freeze• Resources to Help you Prepare • Summary and Closing Remarks

  • 2

    What Is Changing?

    • Medical diagnosis and inpatient procedure code sets:sets:– ICD-9 CM ICD-10 CM

    ICD-10 PCS

    • HIPAA standards for electronic transactions:– Version 4010/4010A Version 5010

    Why the Change?

    • ICD-10 provides more specific data than ICD-9Better reflects current medical practice– Better reflects current medical practice

    – Structure accommodates addition of new codes• The current coding system is running out of capacity and

    cannot accommodate future state of health care

    – Expanded data capture• Quality measurement

    R d di• Reduce coding errors• Better analysis of disease patterns• Track and respond to public health outbreaks• Make claim submission more efficient

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    Why the Change?

    • Version 5010The current version of the standards (Version– The current version of the standards (Version 4010/4010A1) are recognized as lacking certain functionality for health care needs

    – Accommodates the ICD-10 codes

    More on ICD-10 Code Sets

    • ICD-10 CM/PCS consists of two parts: – ICD-10-CM for diagnosis coding in all health careICD 10 CM for diagnosis coding in all health care

    settings• Describes left vs. right, initial vs. subsequent encounter,

    routine vs. delayed healing, and nonunion vs. malunion– ICD-10-PCS for inpatient procedure coding in hospital

    settings• Provides detailed information on procedures and p

    distinct codes for all types of devices

    • CPT coding for outpatient and office procedures is not affected by the ICD-10 transition

  • 4

    More on Version 5010

    • Upgrade to Version 5010 transaction standards by January 1 2012by January 1, 2012

    • Testing should be conducted both internally and with external business partners – Internal testing of Version 5010 should have been

    completed by December 31, 2010– Should have already started external testingShould have already started external testing

    • Testing early will allow you to identify any potential issues, and address them in advance

    Mark Your Calendars

    January 1, 2011                                 Begin external testing of 

    Version 5010 for electronic claims

    December 31, 2011                            External testing of Version 5010 for electronic claims 

    must be complete to achieve Level II Version 5010 


    January 1, 2012                        All electronic claims must use Version 5010; Version 4010 

    claims are no longer accepted


    October 1, 2013                           Claims for services provided 

    f h dApril 1, 2013                                       Train Staff on ICD‐10 CM/PCS

    on or after this date must use ICD‐10 codes for medical diagnosis and inpatient 


  • 5

    CMS’ Dual Role in ICD-10/5010 Implementation

    Internal• As HIPAA covered entity CMS must ensure thatAs HIPAA covered entity, CMS must ensure that

    its business processes, systems, policies and those of its contractors, providers, health plans, etc. are compliant with HIPAA

    • Ensure that state Medicaid programs, as covered entities, are compliant with HIPAA

    • Maintain and update the ICD-9 procedure codes, will do the same for ICD-10 (CDC is responsible for diagnosis codes)


    CMS’ Dual Role in ICD-10/5010 Implementation

    External• Establish and maintain liaison with all externalEstablish and maintain liaison with all external

    industry segments• Share “lessons learned” to inform industry

    efforts to achieve ICD-10/5010 compliance by respective deadlines

    • Raise awareness, extend collaboration to achieve industry-wide compliance

    • Provide audience appropriate educational materials/resources


  • 6


    CMS ICD-10 ImplementationProgram Management

    • Office of E-Health Standards and Services (OESS) – Houses the Program Management Office (PMO) for ICD-10 CMSHouses the Program Management Office (PMO) for ICD 10 CMS

    implementation, in partnership with other Centers/Offices– Convenes ICD-10 Steering Committee to address cross-cutting issues– Responsible for overseeing agency’s ICD-10 coordinated budget across


    • ICD-10 Program Management Office (PMO)– Develop a comprehensive ICD-10 project plan, including pertinent 5010

    milestones– Formulation and management of CMS ICD-10 budget– Conduct external ICD-10 outreach and education– Monitor industry ICD-10 compliance– Ensure coordination between ICD-10 and 5010 implementation projects

  • 7

    CMS ICD-10 Implementation Key Outreach Activities

    Industry Awareness, Outreach and Education• Goal: To ensure that every affected entity successfully transitions to

    Version 5010 and ICD 10 by deadlinesVersion 5010 and ICD-10 by deadlines- Create national awareness; targeted educational products; leverage

    existing partnerships; monitor and assess outreach results.• OESS contractor (Ketchum) will develop and implement a

    communication plan for ICD-10 and 5010 - Focus on small, hard-to-reach and rural providers- Build upon existing CMS resources and materials to ensure

    accuracy and consistency • Outreach to Medicare FFS providers/contractors and States will p

    continue to be conducted by the appropriate CMS component • Identify “non-traditional” external industry partners (for example,

    worker’s compensation programs, actuaries, life insurance companies, etc.)


    CMS ICD-10 Implementation Key Outreach Findings

    Initial informational interviews designed to assess:• Familiarity with ICD-10/Version 5010• Response to transition• Messages, logos and tag lines• Preferred ways of getting information• 12 Focus groups

    - Physicians, medical practice managers, other local providers- Baltimore, Birmingham, Chicago, Sacramento

    • 45 In-Depth interviewsp- Vendors (software developers, billing services)- Payers (HMOs, insurance companies, state BCBS)- Large providers (pharmacy chains, hospital and health care



  • 8

    CMS ICD-10 Implementation Key Outreach Findings

    • Knowledge of ICD-10 is low in small organizationsorganizations– Understanding of Version 5010 is extremely low

    • Knowledge is noticeably higher among larger provider, payer and vendor organizations– Many have already begun to plan for the transition


    CMS ICD-10 Implementation Key Outreach Findings

    • Small health plans initially took a “wait-and-see” approachsee approach

    • Awareness is building, but they still face challenges– Budget, resources

    • They expect CMS and vendors to inform them about the transition and what to doabout the transition and what to do


  • 9

    CMS ICD-10 Implementation Key Outreach Findings

    All audiences want to know:1 K d t1. Key dates2. What they need to do3. Where they can find information4. That information is coming from CMS as a trusted



    CMS ICD-10 Implementation Key Monitoring Activities

    Industry Compliance MonitoringPrevious HIPAA experience demonstrated need to have• Previous HIPAA experience demonstrated need to have compliance monitoring that is specific and consistent to gauge accurate picture of industry readiness and flag problems early on.

    • OESS contractor established a baseline to monitor national health care industry segment readiness and work with CMS components to obtain readiness data forwork with CMS components to obtain readiness data for Medicare FFS, health plans, etc.

    • Also paying attention to industry surveys (WEDI, HIMSS, etc.) for broader picture

  • 10

    Industry Monitoring Findings• HIPAA Modifications is one among many

    competing priorities for the healthcare industrycompeting priorities for the healthcare industry• The Health Plan community is making progress

    on Version 5010, but efforts are still focused internally, and not yet being shared with trading partners

    • Many organizations have achieved high toMany organizations have achieved high to medium compliance through Level IV (tools installation/applications development) on Version 5010, D.0 and 3.0


    Industry Readiness Findings

    • Provider Community is currently less prepared for Version 5010for Version 5010– “We are dependent on vendors to provide the

    software.”– “Small to Medium providers are not actively

    preparing for HIPAA 5010.”– “Rural physicians do not have the IT/business

    staff to support HIPAA Modifications.”

  • 11

    Industry Readiness Findings

    • Lack of testing with trading partners, readiness of business partners to accept or sendof business partners to accept or send transactions is top barrier to success

    • Feedback indicates next top three barriers in order are– Costs of remediation

    Timing of current deadlines– Timing of current deadlines– Current economy

    State Medicaid Agency Readiness

    Experience has taught us to be proactive – early and often – when assessing state Medicaid program readiness for major business process/systems transitions.• Spring 2010 – 188-question survey sent by CMS to all

    state Medicaid programs on Version 5010/ICD-10 preparations, results showed states faced major challenges

    • One-on-one state calls in November 2010CMS in person meetings with states began this• CMS in-person meetings with states began this month– We continue to work closely with all state Medicaid programs to

    assess needs and deliver resources as needed

  • 12


    Tools and Resources

    • ICD-9 and ICD-10 codes are quite different• Tools are needed to convert large data basesTools are needed to convert large data bases• General Equivalence Mappings (GEMs)

    – Designed to aid in converting applications and systems from ICD-9 to ICD-10

    – Bi-directional mappings– “Find and replace” codes or lists of codes

    • Affordable Care Act requires those using GEMS use the version posted to the CMS websitep

    • For small projects – quicker and easier to simply use ICD-10-CM/PCS code books

    • Still need to learn to code with ICD-10• GEMs are not a substitute for learning ICD-10-CM/PCS


  • 13

    2011 ICD-10 & GEM Updates

    • Comments on the General Equivalence Mappings (GEMs) received through Nov 12Mappings (GEMs) received through Nov 12, 2010

    • 2011GEMs updated based on stakeholder comments, and Affordable Care Act requirements met

    • 2011 updates to ICD 10 CM ICD 10 PCS• 2011 updates to ICD-10-CM, ICD-10 PCS, GEMs, and Reimbursement Mappings are now posted at: http://www.cms.gov/ICD10

    GEM Update Example

    • All changes recommended were reviewed, and all recommendations meeting GEMs inclusion criteriarecommendations meeting GEMs inclusion criteria were incorporated in the FY2011 update

    Public comment: ICD-9-CM to ICD-10-CM GEM entry for “Other chronic nonalcoholic liver disease”2010 Entry Recommendation Updated 2011 Entry Comment

    Example571.8 Other chronic 

    571.8 to K76.0 is incorrect. A better map is to K76.8 

    Example571.8 Other chronic nonalcoholic liver disease

    The current entry meets GEMs inclusion criteria. ICD‐9‐CM index entry Fatty, liver is 

    nonalcoholic liver diseaseTo K76.0 Fatty (change of) liver, not elsewhere classified

    with mapping attribute of 10000.

    To K76.0 Fatty (change of) liver, not elsewhere classifiedORTo K76.8 Other specified diseases of liver

    classified to 571.8, so K76.0 is a correct translation. However, based on this recommendation K76.8 was added as a translation alternative, for completeness.

  • 14

    Partial Code Freeze

    • Annual updates to ICD-9 CM and ICD-10 make transition planning difficulttransition planning difficult

    • Vendors, system maintainers, payers, and educators requested a code freeze

    • Last regular, annual updates to both ICD-9 CM and ICD-10 will be made on Oct 1, 2011

    Dates for the Freeze

    The last regular annual On October 1, 2012 there will be only limited code g

    update to both ICD‐9 and ICD‐10 code sets will be made on October 1, 2011

    yupdates to both ICD‐9‐ CM and ICD‐ 10 code sets to 

    capture new technology and new diseases

    On October 1, 2013 there will be only limited updates to the ICD‐10 code sets

    On October 1, 2014 regular updates to ICD‐10 will begin

  • 15

    Help Providers Prepare for ICD-10

    • Identify the current systems and work processes that use ICD 9 codesthat use ICD-9 codes

    • Identify potential changes to work flow and business processes

    • Budget for time and money related to the implementation

    • Allow enough time to test transactionsAllow enough time to test transactions• Assess staff training needs• Communicate implementation plans between

    providers, payers and vendors

    Additional Resources

    CMS ICD-10 website: www.cms.gov/icd10 →

    Get Ready 5010 website: t d 5010← www.getready5010.org

    Professional, clinical, trade associations

  • 16

    Additional Resources


  • 17

    How to Stay Informed

    • ICD-10 National Provider Teleconferences– CMS will be hosting ICD-10 national provider– CMS will be hosting ICD-10 national provider

    teleconferences on May 18 and August 3• CMS ICD-10 Website

    – http://www.cms.gov/ICD10• CMS ICD-10 Industry E-mail Updates

    – https://subscriptions.cms.hhs.gov/service/subscribe.htl? d USCMS 608ml?code=USCMS_608

    • Latest News Page Watch– https://subscriptions.cms.hhs.gov/service/subscribe.ht


    Key Takeaways

    1. Deadlines are not changingShould have already started Version 5010 external– Should have already started Version 5010 external testing

    2. Start taking the steps to prepare now 3. Utilize the resources available from CMS on

    ICD-10Website– Website

    – Trainings/Webinars

  • 18


    We Are Making Progress…• Driving toward 5010 ,with Version 5010 testing for Medicare FFS claims

    underway in January 2011 expanding in April 2011underway in January 2011, expanding in April 2011• ICD-10 PMO provides the structure needed for CMS transition• CMS’ ICD-10 implementation activities now underway

    …But We Still Have Far to Go – We need to…• Consider necessary policy /procedural decisions to support our

    implementation• Raise ICD-10 awareness at basic provider level (small practices)• Continue to engage vendors and clearinghouses• Continue to reinforce compliance date message• Maximize industry resources, deliver practical materials, and find

    synergies where possible• Integrate ICD-10, HITECH Act and health care reform efforts and



    [email protected]

    CMS Exhibit Booth: #502